Background

• The submucous cleft palate (SMCP), a type of cleft palate, is a congenital

condition associated with abnormal development in muscle tissue of the
soft palate [1].
• It is characterized not by either a complete or incomplete cleft palate but by
the disconnected muscle tissue and unbroken lining only in the middle of
the soft palate [2].
• SMCP patients present hypernasal speech from velopharyngeal insufficiency
(VPI) as well as secretory otitis media and hearing loss from the malfunction
of the Eustachian tube.
• Hypernasality is the most common symptom in VPI which accounts for
about 50% of the SMCP patient cases [3].
Background

• Nasal and oral cavities are completely separated from one another
during speaking, swallowing, blowing, and vomiting by closing off
velopharynx.
• Velopharyngeal closure is a particularly important part in producing
pressure-sensitive sounds [4].
• Abnormal muscle development within the soft palate as in SMCP
patients often leads to abnormal velopharyngeal closure, which
results in mispronunciation in speech including hypernasality.
Background
• Surgical intervention is the first treatment choice to treat VPI in SMCP
• Speech aid combined with speech therapy can be applied as an
adjunctive method for VPI after surgery
• No report of speech aid treatment as first choice in the management
of SMCP patients.
 Case presentation
• A 13-year-old female patient visited the outpatient oral and
maxillofacial department of this hospital due to speech problems. In
the intraoral examination, the patient had a short soft palate and bifid
uvula. Also, the movement of the soft palate was very limited during
speech (Figs. 1)
• An objective assessment was conducted :
1. severe hypernasality fig 1. intraoral view during pronouncing /a/. The VP
2. articulation disorder function is not working well during pronunciation
showing VPI. This patient showed severe nasal sound
3. low speech intelligibility.
4. did not show language retardation.
 diagnosed with VPI with SMCP  decided to provide palatal lift
treatment and speech therapy.
Speech assessment
• Device  Nasometer II 6400 (USA) • 3. Sentence (nasal consonant
• Vocal language samples ratio, NCR 0%): /wɔljoil ohu
1. Sustained phonation patatkae kasɔ cokε sɛulɯl cabko
a. Single vowel: /a/,/i/,/e/,/u/ hwajoil sεpjɔke tolaoketta/
b. Double vowel: /ja/,/je/,/wi/
2. Syllable repetition
c. Bilabial plosive: /papi./, /phaphi/,
/p’ap’i/
d. Alveolar plosive: /tati/, /thathi/, /t’at’i/
e. Velar plosive: /kaki/, /khakhi/, /k’ak’i/
f. Aveolopalatal fricative: /cica/,
/chicha/, /c’ic’a/
Results of assessment
Treatment plan
• did not want surgical treatment  conservative treatment using
speech aid/speech therapy without surgery
• The patient showed the closure failure of the velopharyngeal port due
to the short soft palate and insufficient contraction of the palatal
muscles.
• a palatal lift was selected  the palatal lift should be fitted for all
hours except when sleeping.
• The assessment was scheduled to be performed once a month, and
weekly speech therapy was recommended  the patient was only
able to come in once or twice a month.
• Palatal lift was made and applied to the patient (Fig. 3). Speech
therapy : visual feedback, muscle training, perception training,
and speech assessment using nasometer was performed at each
visit.

Fig 2. Palatal lift: The functional part can elevate

the soft palate
Results
• The articulation of the single vowel /i/ improved the most after
treatment, from 88% prior to treatment.
• each vowel presented different reductions in vowel
pronunciation, all vowels showed decreased hypernasality (Fig.
4).

Fig 4. Evaluation of hypernasality (vowels).

Measurements of nasal emission energy in vowels
using nasometer. After initiation of speech aid
therapy, the nasality decreases with time
 Fig. 5 Evaluation of hypernasality (syllable repetition). Measurements of nasal emission energy in syllable repetition
using nasometer. After initiation of speech aid therapy, the nasality decreases with time

• Nasalance in syllable repetition indicated hypernasality in all

pronunciations prior to treatment, it gradually decreased to
the normal nasalance range as treatment progressed (Fig. 5).
 • Based on these results, we
concluded that the
hypernasality, which was a major
symptom of the patient, was
successfully improved.

Fig. 6 Evaluation of hypernasality (sentence). Measurements of nasal emission energy

in 'nasal consonant ratio (NCR) 0% sentence" using nasometer. Nasalance percentages
less than or equalto 20% are considered to represent the absence of nasality and are
marked with a green line. The nasality was significantly decreased when compared
with 7 months after installation
Discussion
• Calnan [6] defined SMCP as the imperfect union of muscles that cross the
soft palate, and patients with SMCP have shown soft palate shortness
and velopharyngeal closure  hypernasality and unintelligible speech
• Calnan’s triad as criteria for diagnosis SMCP :
1. bifid uvula
2. clear lining in the middle of the soft palate
3. absence of a bony notch in the posterior margin of the hard palate
 not all patients with SMCP show this triad of signs, some patients
present only one or two signs.
Con’t
• Cleft palate muscle malposition may occur in the absence of the triad
signs, which is a condition that has been identified as occult
submucous cleft palate (OSCP)
• OSCP is difficult to recognize by oral examination alone but can be
confirmed during surgery [2, 8].
Con’t
• The major symptoms of SMCP are hypernasality (51%) due to motile
incompetence in the soft palate and pharyngeal muscles, as well as
conductive hearing loss (45%) [3, 9].
• Palatoplasty is performed to connect palate muscles to stretch the
length of the soft palate.
• The postoperative frequency of VPI has been reported to range from
20 to 50%, even with successful surgery [10].
• it is necessary to proceed with prosthetic treatment using a
combination of speech aid and speech therapy to provide an ideal
treatment [9].
Con’t
• Sphincteric interaction of the palate in the pharynx is very important
for producing intelligible speech [10].
• Speech problems  palate muscles function inappropriately.
• There are three muscles that affect velopharyngeal closure :
1. levator veli palatini muscles
2. Superior pharyngeal constrictor muscles
3. uvula muscles
Velopharyngeal dysfunction (VPD)

• a general term that describes an inappropriate function

of velopharyngeal port.

Velopharyngeal insufficiency (VPI)

• a congenital or acquired condition in which the

velopharynx has not closed due to a lack of soft tissue.
• The most common cause of VPI :
cleft palate, including SMCP and occult submucous cleft palate. patients
present hypernasality, nasal emission, and reduced speech intelligibility
[4].
• Velopharyngeal incompetence  functional velopharyngeal
impairment (neuromuscular diseases, such as cerebral palsy,
myotonic dystrophy, and cerebral vascular accidents.)
• velopharyngeal mislearning (VPM) indicates speech problems with
learning a language, which are not caused from anatomical or
neurophysiological reasons [12].
 Surgical
Velopharyngeal intervention
insufficiency and combined with
incompetence prosthetic treatment
and speech therapy.

surgical intervention is the first line of treatment. Although there

are various surgical procedures, the operation has a success rate of
about 50%. Speech aids can be a good alternative when surgical
treatment is not considered.
Speech aid consists of
• the maxillary portion (palatal portion) covering the palate,
• the pharyngeal portion (functional part)
• and the palatal extension that connects between of them.

Speech aids can be divided into

• speech bulbs directly closes the opened velopharyngeal port during
pronouncing
• and palatal lift is placed on the soft palate and elevates the soft palate to
the posterosuperior position.
• Periodic speech therapy and assessment are essential
• The nasality and speech intelligibility of the patients are normal
without nasal emission, time-based reduction program of the
functional part can be initiated
• the patient sounds the same whether the appliance is worn or
removed, the appliance may then be removed permanently.
In this case, the patient showed much progress in nasalance and
speech intelligibility using palatal lift and speech therapy
without any surgical intervention.

It suggests that conservative treatment without surgical

intervention may be an effective treatment for SMCP patients
with VPI.
Conclusion

50% of patients with submucous cleft palates suffer from speech problem
due to velopharyngeal insufficiencies.

Surgical intervention is the first treatment option to be considered.

Speech aid without any help of surgical management can be another treatment
option for speech problem caused by SMCP